A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Set client-centered, measurable and realistic goals.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Collect and organize client data.
The Correct Answer is D
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cognitive dysfunction: This is a broad term that includes various types of cognitive impairment.
B. Alzheimer's disease: This is a specific type of dementia, but it doesn’t specifically describe the timing of confusion.
C. Sundowning syndrome: This term describes increased confusion and agitation in the late afternoon and evening. It’s commonly seen in individuals with dementia.
D. Night-time confusion: This is a general term and doesn't specifically relate to the characteristic pattern of sundowning.
Correct Answer is C
Explanation
A. Percussion: Percussion is typically performed before palpation. It helps to detect differences in density of abdominal contents, fluid presence, and gas patterns.
B. Auscultation: Auscultation is performed before any palpation or percussion to prevent altering bowel sounds. It is typically the second step after inspection.
C. Palpation: Palpation is used last during an abdominal assessment to prevent altering the characteristics of bowel sounds and to ensure that any tenderness or abnormal masses are identified after a thorough initial assessment. Palpation can cause changes in bowel sounds and tenderness.
D. Inspection: Inspection is always the first step in any physical examination. It allows for a visual assessment of the abdomen, looking for distension, asymmetry, and skin changes.
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